JAMA Forum: A Breath of Bad Air: Trump Environmental Agenda May Lead to 80 000 Extra Deaths per Decade

President Donald Trump and Environmental Protection Agency (EPA) Administrator Scott Pruitt have pledged to reexamine landmark environmental policies and to repeal regulations. In their view, excessive regulations are harming US industry, and thus reducing regulation will be good for business. As Donald Trump has said, seemingly without irony, “We are going to get rid of the regulations that are just destroying us. You can’t breathe—you cannot breathe.”

As has become apparent, however, it is the changes Trump is proposing that are likely to make breathing more difficult. A central feature of his agenda is environmental damage: making the air dirtier and exposing people to more toxic chemicals. The beneficiaries, in contrast, will be a relatively few well-connected companies.

The Trump AgendaIn pursuit of its wide-ranging environmental agenda, the administration has already reversed or proposed to reverse more than 60 environmental rules. The full extent of the effects on health has not been tabulated and is hard to quantify, but guesses can be made for some of the larger ones (see the Table).

The largest health consequences are likely to come through changes in air quality. The Trump administration has announced its intention to repeal the Clean Power Plan rule, President Barack Obama’s signature policy on climate change. The rule provides for the EPA to assign each state a goal for limiting emissions from existing power plants and gives the states latitude in meeting those goals, such as switching from coal to natural gas or building new wind or solar farms. Based on the regulatory impact analysis done by the EPA when the rule was implemented (as well as otheranalyses), repealing the rule would lead to an estimated 36 000 deaths each decade and nearly 630 000 cases of respiratory infection in children alone.

Other elements of the administration’s environmental agenda will also affect health, though it is hard to know by how much. Withdrawing from the Paris agreement on global warming, imposing tariffs on solar panels, and rolling back the “once in, always in” rule for industrial plants will all lead to increases in fine particulate matter and additional exposure to pollutants such as sulfur dioxide, nitrogen oxides, mercury, and others that adversely affect respiratory and cardiovascular health.

Water quality is also being targeted. The Trump EPA has proposed to rescind the Waters of the United States rule published in 2015, which brought more US streams and wetlands areas under the Clean Water Act. Rivers and streams are sources of drinking water for more than 130 million people and if polluted, might pose major health risks. The rule itself does not mandate any specific changes in water cleanliness, so we do not estimate a specific health consequence of repealing this rule.

Finally, the administration is proposing to withdraw or not implement regulatory actions affecting particular chemicals shown to be harmful to health, including lead, agricultural pesticides, and coal ash waste. Exposure to these hazardous substances will affect fewer people than the number of individuals affected by air pollution, but each will affect a concentrated number. As Christine Todd Whitman, head of the EPA under President George W. Bush, said: “You stop enforcing those regulations and [deaths] will go way up.”

Overall, an extremely conservative estimate is that the Trump environmental agenda is likely to cost the lives of over 80 000 US residents per decade and lead to respiratory problems for many more than 1 million people. This sobering statistic captures only a small fraction of the cumulative public health damages associated with the full range of rollbacks and systemic actions proposed by the Trump administration.

An Attack on ScienceOne might imagine that the science that supported enactment of these rules would make repealing them difficult. But that is not the case. Even as it is targeting environmental rules, the Trump administration is taking aim at the use of science that supports public policy.

Scott Pruitt recently signed a controversial rule stipulating that policy can be based only on research for which the underlying data have been made accessible to the general public. The idea is to remove most observational studies of health effects of air pollution exposure from being considered in regulatory settings, unless the individual health records are made publicly available. This is a nearly impossible task because the health data are collected under the agreement to maintain patient confidentiality. With no evidence of harms (because of constraints on presenting the available evidence), regulations cannot be sustained. On April 23, 985 scientists sent him a letter urging him to abandon the proposal.

Fortunately for those interested in public health, the regulatory process will take many years. Whoever is sworn in as President in January 2021 will have a large effect on whether the Trump administration’s full environmental agenda goes into effect.

Implications for Physicians and PolicyFor physicians, the manifestation of these changes is likely to be an increase in disease and number of deaths. Respiratory and cardiovascular problems are most likely, but a wide variety of conditions are likely to be seen. Poor, black, or elderly populations are likely to be affected the most. People working with chemicals in industrial settings will also be affected, as will people who live in areas with high concentrations of power plants such as the Ohio River Valley from Indiana to Pennsylvania, and in the southeast from Alabama and Georgia to Maryland.

One could debate the merits of these tradeoffs if there were a large number of people who would benefit economically from these changes. In practice, however, any economic benefits are not likely to accrue to those most in need. Employment is down in many fossil fuel industries because technology has made workers less necessary for production, not because of environmental regulations. And even if a large number of coal jobs were restored, it would come at the expense of employment in new industries such as wind and solar, which are already being hurt by the Trump administration policies. Not having to comply with environmental rules will increase corporate profits, but not worker bank accounts.

Overall, the ultimate effects of the Trump administration’s policies seem clear, even through the haze they will create.

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About the authors:David M. Cutler, PhD, is the Otto Eckstein Professor of Applied Economics in the Department of Economics and Kennedy School of Government at Harvard University and a member of the Institute of Medicine. He served on the Council of Economic Advisers and the National Economic Council during the Clinton Administration and was senior health care advisor to Barack Obama’s presidential campaign. He is a commissioner on Massachusetts’ Health Policy Commission. He is the author of the The Quality Cure (2014) and Your Money or Your Life (2004). He tweets at @cutler_econ. (Image: Ted Grudzinski/AMA)

Francesca Dominici, PhD, is professor of biostatistics at the Harvard T.H. Chan School of Public Health and codirector of the Harvard Data Science Initiative. Her research focuses on the development of statistical methods for combining information across heterogenous data sources. Her team develops new methods for causal inference to estimate health effects of environmental exposures and climate change and to inform regulatory policy. Her studies have informed air quality policy and led to more stringent ambient air quality standards in the United States. (Image: Kris Snibbe/Harvard staff photographer)

About The JAMA Forum:JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.